children
Systematic Review
Management of Traumatic Nerve Palsies in Paediatric
Supracondylar Humerus Fractures: A Systematic Review
Christy Graff 1,2,3, *, George Dennis Dounas 1,2,3 , Maya Rani Louise Chandra Todd 2,3 , Jonghoo Sung 1
and Medhir Kumawat 2
Citation: Graff, C.; Dounas, G.D.;
Todd, M.R.L.C.; Sung, J.; Kumawat,
M. Management of Traumatic Nerve
Palsies in Paediatric Supracondylar
Humerus Fractures: A Systematic
Review. Children 2023, 10, 1862.
https://doi.org/10.3390/
children10121862
Academic Editors: Christiaan J.
A. van Bergen and Joost W. Colaris
Received: 17 October 2023
Revised: 20 November 2023
Accepted: 22 November 2023
Published: 27 November 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Children 2023, 10, 1862. https://doi.org/10.3390/children10121862
1 The Women’s and Children’s Hospital, North Adelaide, SA 5006, Australia; jonghoo.sung@sa.gov.au (J.S.)
2 Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia;
medhir.kumawat@student.adelaide.edu.au (M.K.)
3 The Royal Adelaide Hospital, Adelaide, SA 5000, Australia
* Correspondence: christy.graff@sa.gov.au
Abstract: Purpose: Up to 12% of paediatric supracondylar humerus fractures (SCHFs) have an
associated traumatic nerve injury. This review aims to summarize the evidence and guide clinicians
regarding the timing of investigations and/or surgical interventions for traumatic nerve palsies after
this injury. Methods: A formal systematic review was undertaken in accordance with the Joanna
Briggs Institute (JBI) methodology for systematic reviews and PRISMA guidelines. Manuscripts
were reviewed by independent reviewers against the inclusion and exclusion criteria, and data
extraction, synthesis, and assessment for methodological quality were undertaken. Results: A total
of 51 manuscripts were included in the final evaluation, reporting on a total of 510 traumatic nerve
palsies in paediatric SCHFs. In this study, 376 nerve palsies recovered without any investigation
or intervention over an average time of 19.5 weeks. Comparatively, 37 went back to theatre for
exploration beyond the initial treatment due to persistent deficits, at an average time of 4 months. The
most common finding at the time of exploration was entrapment of the nerve requiring neurolysis. A
total of 27 cases did not achieve full recovery regardless of management. Of the 15 reports of nerve
laceration secondary to paediatric SCHFs, 13 were the radial nerve. Conclusions: Most paediatric
patients who sustain a SCHF with associated traumatic nerve injury will have full recovery. Delayed
or no recovery of the nerve palsy should be considered for exploration within four months of the
injury; earlier exploration should be considered for radial nerve palsies.
Keywords: fracture; humerus; nerve injury/palsy/palsies; pediatric/paediatric; supracondylar
1. Introduction
Nerve palsy is a common complication of paediatric supracondylar humerus fractures
(SCHFs), affecting approximately 12% of patients [1,2]. The median nerve proper, or
its branching anterior interosseous nerve, is the most commonly impaired nerve from
extension-type fractures, while the ulnar nerve is the most at risk of injury in flexion-type
fractures [1–3]. Over 70% of cases of nerve palsies are present pre-operatively [1].
From the literature and clinical opinion, most reported nerve injuries are managed with
a ‘watch and wait’ approach, based on the assumption that the nerve injury is a transient
neuropraxia, although the exact resolution details are often unclear [4–6]. There is currently
no clear evidence regarding the timing of investigation, intervention, and recovery.
This systematic review aims to summarize the current evidence and guide clinicians
regarding the timing of investigation and/or surgical intervention for traumatic nerve palsies
sustained at the time of injury in paediatric SCHFs and compare the outcomes of nerve palsy
in this population with surgical intervention compared with expectant management.
https://www.mdpi.com/journal/children
Children 2023, 10, 1862 2 of 11

2. Methods
The review has been conducted in accordance with the Joanna Briggs Institute (JBI)
methodology for systematic reviews of effectiveness with reference to the a priori protocol
published in the same journal [7,8]. The review has been registered with the International
Prospective Register of Systematic Reviews PROSPERO (CRD42019121581).
A comprehensive search strategy was conducted on 7 June 2021 (Supplementary S1).
Randomised controlled trials, cohort studies, case series, and case studies published after
1950 were included. The databases searched were Ovid Medline, Embase, and Cochrane
Central, as well as a grey literature search using Google Scholar with the first 200 results
returned also reviewed. The bibliographies of the accepted manuscripts were reviewed to
identify other relevant published research. The search was re-executed on 23 May 2022,
due to the longevity of data curation.
The aim of the study was to compare the effectiveness of operative versus expectant
management on the recovery of nerve palsies in paediatric supracondylar fractures. The
inclusion criteria were papers that included:
- A paediatric patient with;
- An ipsilateral traumatic upper limb nerve palsy after a SCHF;
- With no pre-existing neurological impairment.
Studies were excluded if:
- They did not provide details regarding follow up or the outcome of the traumatic
nerve palsy;
- It was not possible from the reporting to separate individual outcomes from large
groups of nerve palsies.
Sequential screening of the manuscripts by title, abstract, and full text were performed
by two independent reviewers to determine suitability based on the inclusion and exclusion
criteria. The results of the final search were reported in accordance with the preferred
reporting items for the systematic reviews and meta-analysis (PRISMA) guidelines [9]
(Supplementary S2).
Data extraction was performed by two independent reviewers using a prescribed
extraction form. Each eligible manuscript underwent critical appraisal and assessment of
methodological quality by two independent reviewers using standardized critical appraisal
instruments from the Joanna Briggs Institute (JBI) for Systematic Reviews and Research
Synthesis (Supplementary S3–S6) [8]. Cohort studies with complete follow up were scored
out of eleven, case series out of ten, and case reports out of eight. Cohort studies without
confounding factors or incomplete follow up were scored out of ten, and cohort studies
without confounding factors and without incomplete follow up were scored out of nine.
Discrepancies between reviewers at all stages were resolved by a senior reviewer.
The primary outcome was nerve palsy recovery, ranging from “full recovery” to “no
recovery” as a descriptive measure. Secondary outcomes include time to recovery, modality
of treatment, use and timing of investigations, findings at operation, and duration of
follow up. Data were synthesised in narrative and tabular format. Due to considerable
clinical heterogeneity, a meta-analysis was not performed. Where appropriate, frequencies,
percentages, and summaries of data were included for analysis.

3. Results
A total of 7919 results were identified on initial search. All of the results were collated
and uploaded into EndNote version X.9 (Clarivate Analytics, Philadelphia, PA, USA) and
de-duplication occurred, with a final number of 2744 articles retrieved [10]. After title and
abstract screening, there were 218 manuscripts reviewed in full including bibliography
reviews, of which 51 met the inclusion criteria and were included in this systematic review
as demonstrated in the PRISMA flow diagram (Figure 1) [9]. From the final 51 manuscripts,
16 were case reports/series with the remainder being cohort studies. There were 509 nerve
Children 2023, 10, x FOR PEER REVIEW 3 of 11

reviews, of which 51 met the inclusion criteria and were included in this systematic review
Children 2023, 10, 1862 as demonstrated in the PRISMA flow diagram (Figure 1) [9]. From the final 51 manu- 3 of 11
scripts, 16 were case reports/series with the remainder being cohort studies. There were
509 nerve palsies described, with the median nerve most commonly affected and the most
common fracture type
palsies described, withreported as Gartland
the median type
nerve most 3. No studies
commonly wereand
affected excluded due
the most to bias
common
(Table 1).
fracture type reported as Gartland type 3. No studies were excluded due to bias (Table 1).

Figure 1. PRISMA flow diagram of the final search.

Children 2023, 10, 1862 4 of 11

Table 1. Main characteristics of studies included in analysis.

No. of Time to Final

Study Risk of
Paper Nerve Surgical Exploration at ORIF Delayed Surgical Exploration Follow up in
Type Bias
Palsies Months
Timing
No Reason Findings No Findings
in Months
Ababneh M et al. [11] RCS 8/10 7 0 n/a n/a 0 n/a n/a 6
Aronson DC et al. [12] RCS 9/11 1 0 n/a n/a 0 n/a n/a 12
Describing Median in
Ay S et al. [13] RCS 7/10 9 9 open surgical fracture site ×3, 0 0 0 3
technique radial kinked ×6
Barrett KK et al. [14] RCS 8/8 35 0 n/a n/a 0 n/a n/a 7.4
Bertelli JS & Ghizoni Entrapment ×2,
RCS 9/11 6 0 n/a n/a 6 6–9 16–24
MF [15] laceration ×4
Boyd DW & Aronson
RCS 8/10 3 0 n/a n/a 0 n/a n/a 12
DD [16]
Brown IC et al. [5] RCS 8/9 14 0 n/a n/a 0 n/a n/a 6
3 = VE
Campbell CC et al. [17] RCS 7/9 25 4 In continuity 0 n/a n/a 10
1 = FCR
Chakrabarti AJ
RCS 7/10 1 1 NE Complete division 0 n/a n/a 36
et al. [18]
Cheng JC et al. [19] RCS 7/9 19 1 VE In continuity 0 n/a n/a 4–13
Fibrous
7.5 scarring ×6,
Culp RW et al. [20] RCS 8/9 18 0 n/a n/a 9 25
(mean) entrapment ×2,
laceration ×2
Davis RT et al. [21] RCS 7/9 10 0 n/a n/a 0 0 0 48
Devkota P et al. [22] RCS 10/10 6 0 n/a n/a 0 0 0 3
Dormans JP et al. [23] CS 5/5 7 0 n/a n/a 0 0 0 27
Garg Bet al. [24] CS 8/11 1 1 NE In continuity 0 n/a n/a 14–36
Gosens T et al. [25] RCS 9/11 34 10 VE and FCR In continuity 0 n/a n/a 6
Horst M et al. [26] RCS 8/9 2 0 n/a n/a 0 n/a n/a 17 (mean)
Entrapment in
Ippolito E et al. [27] RCS 6/9 14 0 n/a n/a 1 8 132 (longest)
scar tissue
Jones ET et al. [28] CS 8/8 6 0 n/a n/a 0 n/a n/a 24
Interposed
Karlsson J et al. [29] CS 8/8 4 4 VE and FCR between bone 0 n/a n/a 72–108
fragments
In continuity ×2,
Khademolhosseini M entrapment in
RCS 7/9 9 4 FCR 0 n/a n/a 8
et al. [30] fracture ×1,
contusion ×1
Khan AQ et al. [31] RCS 8/10 8 0 n/a n/a 0 n/a n/a 3
Entrapment at
Khan MY et al. [32] PCaS 8/10 25 2 VE 0 n/a n/a 3
fracture site
Kirz PH and Marsh
CS 8/10 11 0 n/a n/a 1 4 Lacerated 65
HO [33]
Kiyoshige Y et al. [34] RCS 7/10 6 0 n/a n/a 0 n/a n/a 5–120
Krusche-Mandl I Compressive
RCS 8/11 8 0 n/a n/a 1 2 12
et al. [35] scar tissue
Kuoppala E et al. [36] CS 10/10 1 0 n/a n/a 0 n/a n/a 12
Encased in
Lalanandham T
CR 7/8 1 0 n/a n/a 1 2 callus; unable to 14
et al. [37]
be retrieved
Larson AN et al. [38] RCS 9/11 2 0 n/a n/a 0 n/a n/a 10
Encased at
Leonardi LL et al. [39] CS 8/10 3 0 n/a n/a 1 3 12
fracture site
Li YA et al. [40] RCS 7/11 7 0 n/a n/a 0 n/a n/a 34
Children 2023, 10, 1862 5 of 11

Table 1. Cont.

No. of Time to Final

Study Risk of
Paper Nerve Surgical Exploration at ORIF Delayed Surgical Exploration Follow up in
Type Bias
Palsies Months
Timing
No Reason Findings No Findings
in Months
Severe
compression
10 in continuity; ×3, laceration
Louahem DM 1 radial nerve and retraction
RCS 8/11 66 11 FCR 4 3 18
et al. [41] complete ×1 (lacerated
laceration radial nerve
failed suture
repair)
1× at
48 h,
Entrapment at 2× at Tethered or
Mangat et al. [42] CS 10/10 9 5 VE 4 12
fracture site 2 weeks, entrapped
1× at
3 weeks
Laceration ×1,
Marck KW et al. [43] CR 8/8 2 2 VE 0 n/a n/a 18–48
traction ×1
Martin DF et al. [44] CR 8/8 1 0 n/a n/a 1 6 Laceration 18
McGraw J. et al. [45] RCS 8/10 17 2 FCR and VE In continuity 1 6 Laceration 14
Entrapment in
Oh CW et al. [46] RCS 7/10 4 1 VE 0 n/a n/a 3
fracture
Encased in
Post M. et al. [47] CR 8/8 1 0 n/a n/a 1 6 30
callous
Kinked ×21,
Rasool MN et al. [48] CS 8/10 27 27 VE 0 n/a n/a 6
intact ×6
Entrapped in
Reigstad O et al. [49] CS 8/10 2 2 VE 0 n/a n/a 10
fracture site
Sairyo K et al. [50] CR 8/8 1 0 n/a n/a 1 3 Laceration 8
Silva M et al. [51] RCS 8/11 11 0 n/a n/a 0 n/a n/a 6
Solak S et al. [52] RCS 7/9 6 0 n/a n/a 0 n/a n/a 36
Entrapment in
Steinman et al. [53] RCS 8/9 1 1 FCR 0 n/a n/a 1–9
fracture site
Thorleifsson R Entrapment in
CR 8/8 1 0 n/a n/a 1 2.5 120
et al. [54] the fracture site
Entrapment at the Entrapment at
Tokutake et al. [55] CR 8/8 2 1 NE 1 3 4–6
fracture site the fracture site
Entrapment at
Tomaszewski et al. [56] RCS 7/10 22 0 n/a n/a 2 2 10
the fracture site
Tunku-Naziha TZ Contused but in
RCS 7/9 2 2 VE 0 n/a n/a 1.5
et al. [57] continuity
Complete
van Vugt AB et al. [58] RCS 7/9 23 1 VE 0 n/a n/a ‘Good result’
laceration
Entrapment in
Yano K et al. [59] CR 8/8 1 0 n/a n/a 1 11 36
callus
Yaokreh JB et al. [60] RCS 7/9 8 0 n/a n/a 0 n/a n/a 5–6
RCS = retrospective cohort study; CS = case series; PcaS = prospective case series; CR = case report. VE = vascular
exploration; FCR = failed closed reduction; NE = nerve exploration; n/a = Not Applicable.

There were 372 traumatic nerve palsies which had full recovery with no intervention
(such as nerve exploration) or investigation (such as imaging or nerve conduction studies)
undertaken (73.9%) (see Table S1 Supplementary S7). The mean duration of time to full
recovery at final follow up in these patients was 19.5 weeks (approximately 5 months)
(ranging from 3 days to 1 year). Eight nerve palsies had no intervention (such as nerve
exploration) or investigation (such as imaging or nerve conduction studies) and were
not fully recovered at last follow up. Davis et al. [21] described an ulnar nerve palsy
with sensory disturbance at the 4-year follow up, and two radial nerve palsies with wrist
extension weakness at the 4-year follow up. Van Vught et al. [58] reported one patient with
ulnar, median, and radial sensory loss after a patient presented to them after 5 days with
Children 2023, 10, 1862 6 of 11

Volkmann’s ischaemic contracture. Yaokreh et al. [60] reported on two nerves that ‘required
electrophysiological studies’ at final follow up but no other detail was given.
There were 26 traumatic nerve palsies which did not document full recovery by the
final follow up (5.3%) (see Table S2 Supplementary S7).
There were 92 (18%) nerve palsies which underwent exploration at the time of initial
operation (see Table S3 Supplementary S7) of which 89 were described as a secondary intention
whilst exploring the brachial artery or an open fracture or converting to open reduction. Three
were explored due to surgeon preference of treatment of nerve palsies at presentation [1,19,54].
Eighty-eight which were explored at the time of the initial operation had full recovery by the
final follow up, one incomplete recovery, and three were lost to follow up. The findings at
exploration in forty-six out of ninety-two nerves were tethered or entrapped in the fracture
site, thirty-seven were in continuity, three lacerated, and four contused.
A total of 37 nerves (7.3%) underwent delayed exploration with an average time of
4.4 months (0.5 to 11 months) (see Table S4 Supplementary S7). It was found that 27 were
recorded as entrapped in the fracture site/callous/scarring and 10 were found to be completely
transected. The radial nerve was involved in sixteen cases, while the median in twelve, and
the ulnar in nine. Full recovery at final follow up was reported in 26 nerves. One radial nerve
was lacerated, explored, and repaired primarily, but then did not recover, and went on to
have a delayed exploration [41]. The primary repair was found to have failed, and was then
managed with a nerve graft, and ultimately, tendon transfers.
A total of 13 nerves were found to be completely lacerated on exploration (see Table S5
Supplementary S7). Interestingly, 10 of these were radial nerves. Most of these occurred at
the time of the injury, prior to reduction (see Table S5 Supplementary S7).

4. Discussion
Our systematic review focused on traumatic nerve palsies in paediatric supracondylar
humerus fractures. Iatrogenic or K-wire-associated nerve palsies represent a different
spectrum of nerve trauma and have been described elsewhere [30,61]. This review rep-
resents the most current comprehensive description of outcomes after traumatic nerve
palsies in paediatric supracondylar humerus fractures in the literature, with a total of
510 nerve injuries identified. The characteristics of a Gartland type 3 fracture were consis-
tent with previously reported papers, supporting the opinion that neurological injury is
more prevalent amongst more severely displaced fractures [2,24,62]. A total of 18 of the
51 papers did not report the Gartland type, and therefore we did not think a percentage of
Gartland type would be accurate to report.
The previous literature reports that 86–100% of nerve injuries will recover sponta-
neously by 6 months, with a mean time of approximately 3 months [41,63]. Most nerves
in the current series were managed expectantly, and had full spontaneous recovery, in
keeping with this ‘watch and wait’ policy which is consistently advocated in the literature
for patients with anatomical reduction [17,58]. However, an adequate reduction does not
rule out the possibility of entrapment and does not account for lacerations [42,55].
A comparison of time frame to full recovery between no exploration, exploration at
initial operation, and delayed exploration was unable to be calculated in this review as the
majority of papers reported recovery ‘at time of final follow up’ or provided a broad range,
such as 1 day to 10 months or 1 to 4 years [17,43]. It is important to recognize that the ‘time
to full recovery’ for nerve palsies is the time of final follow up. The literature is not robust
enough to determine how long it took for the nerve palsies to fully recover.
It was found that 7.4% of nerve palsies required delayed exploration due to persistent
deficits or stagnated recovery at an average of 4 months. Exploration has been advocated
for if there is no clinical recovery from 6 weeks to 3 months [30,41,64]. If the nerve is found
in continuity at 3 months and is neurolysed, there is a trend to complete recovery [20,58].
Incomplete recovery was more common after complete nerve transection, or if exploration
occurred after 4 months. There were 13 reports of nerve laceration secondary to paediatric
SCHFs, of which 10 were the radial nerve, and had poorer outcomes.
 Children 2023, 10, x FOR PEER REVIEW 7 of 11

Children 2023, 10, 1862 7 of 11

occurred after 4 months. There were 13 reports of nerve laceration secondary to paediatric
SCHFs, of which 10 were the radial nerve, and had poorer outcomes.
Nerve exploration is recommended to be undertaken when there is no evidence of
Nerveorexploration
clinical is recommended
electrophysiological to be undertaken
improvement by 8 weeks when there
to 6 ismonths
no evidence
after of clinical
injury
or[19,20,45,50,63,65].
electrophysiological improvement
Ultrasound by 8advocated
has been weeks to 6asmonthsuseful to after injurythe
evaluate [19,20,45,50,63,65].
continuity of
Ultrasound
the nerve in has been advocated
a small percentage as usefulpre-operatively,
of series to evaluate the intraoperatively,
continuity of theand nerve in a small
post-oper-
percentage of series pre-operatively,
atively; ultrasound, however, is highlyintraoperatively,
user dependent and post-operatively;
[55]. Only three ultrasound,
of the papers however,
that
is met
highly theuser dependent
inclusion [55].reported
criteria Only three theofusetheofpapers that met
ultrasound the inclusion
[39,47,55]. Nerve criteria reported
conduction
thestudies
use of andultrasound
EMG can [39,47,55].
be poorly Nerve conduction
tolerated studies
in children, and may
which EMGexplain
can be whypoorly tolerated
most series in
children,
did notwhich may in
use these explain
their why most series
management of did
nervenotpalsies.
use these in their management
Magnetic resonance imaging of nerve
(MRI) Magnetic
palsies. can sometimes require
resonance a general
imaging anaesthetic
(MRI) in this age
can sometimes groupabut
require can often
general be use- in
anaesthetic
fulage
this in older
groupchildren to investigate
but can often be usefulnerve
in olderinjuries.
children Notostudy reported
investigate on the
nerve use ofNo
injuries. MRI.
study
Additionally,
reported on thenewer
use ofsurgical techniques such
MRI. Additionally, neweras nerve
surgicaltransfer have not
techniques suchbeenasdocumented
nerve transfer
at all
have not inbeen
the current literature.
documented at allFrom this
in the systematic
current review,
literature. our this
From recommendation
systematic review,wouldour
be nerve exploration
recommendation wouldifbethere
nerveis exploration
no or little clinical
if there recovery at 3clinical
is no or little months, and exploration
recovery at 3 months,
andwithin 4 months,
exploration except
within in the except
4 months, case toin thetheradial
case tonerve, whichnerve,
the radial is discussed
which isbelow.
discussedFor below.
the
consideration of exploration in this time frame, investigations such
For the consideration of exploration in this time frame, investigations such as ultrasound, MRI, as ultrasound, MRI,
and/ornerve
and/or nerveconduction
conductionstudies
studiesshould
should bebe considered
considered at at 6–12
6–12 weeks
weeks (Figure
(Figure 2). 2). Liaison
Liaison with
with the local nerve injury unit is imperative regarding the timing of
the local nerve injury unit is imperative regarding the timing of referral for the consideration referral for the con- of
sideration
nerve of nerve
exploration, exploration,
repair, repair, nerve
nerve grafting, nerve grafting,
transfer, nerve
and/or transfer,
tendonand/or tendon trans-
transfer.
fer.

Figure 2. Algorithm for the management of traumatic nerve palsies after paediatric supracondylar
Figure 2. Algorithm for the management of traumatic nerve palsies after paediatric supracondylar
humerus fractures.
humerus fractures.
The majority of included papers did not have a primary objective of nerve palsy out-
The majority of included papers did not have a primary objective of nerve palsy
comes; they were commonly reported on only as a complication in part of a wider review
outcomes; they were commonly
of SCHF management techniques.reported on described
Those that only as anerve
complication in part
palsy in detail of aoften
were wider
review
case studies and thus have impacts of selection bias confounding the results. The 5% were
of SCHF management techniques. Those that described nerve palsy in detail of
often case studies and thus have impacts of selection bias confounding the results. The 5%
of nerves that did not fully recover in this series is likely overinflated due to the selection
bias of persistent deficits being reported in case series. Our review included eight case
reports, focusing only on nerves that were lacerated or entrapped, and so were not typical
of the normal pathway of nerve palsies after paediatric supracondylar humerus fractures.
Children 2023, 10, 1862 8 of 11

There is unfortunately very limited literature dedicated to the management of these injuries
from injury to full recovery, which is surprising considering the importance of the topic.
Retrospective or prospective data from large centres or multicentre trials on the recovery of
nerve palsies in this population is required for improved confidence in recommendations
for management.
Another limitation is that two of the largest series describing 425 nerve palsies were
excluded by full text; a report of the interventions and outcomes was unclear for the
purposes of this review. The authors were contacted for further details which were not able
to be obtained at the time of submission [63,66].
The incidence of complete lacerations of nerves after paediatric SCHFs has never
been reported before. This systematic review suggests that the radial nerve is more often
lacerated than other nerves, which is a new finding to our knowledge. This needs further
investigation, and a radial nerve that is not recovering after a paediatric SCHF may need
earlier investigation or exploration.

5. Conclusions and Recommendations

This is the largest systematic review to report outcomes of investigations and inter-
ventions on the recovery of traumatic nerve palsies in paediatric patients after sustaining a
supracondylar humerus fracture. From the findings, the authors recommend the below to
be included in discussions with parents of these patients:
i. Almost all nerves will fully recover without intervention or investigation within the
first 4–5 months;
ii. In nerves with little or no recovery at 3 months, a return to theatre before 4 months is
recommended, as full recovery was more likely than those that were not explored,
unless the nerve was lacerated;
iii. Although rare, complete transection was reported more commonly in the radial nerve;
no recovery of the radial nerve at 6 weeks should alert earlier exploration;
iv. A small percentage (<5%) of traumatic nerve palsies will not fully recover regardless
of investigation or surgical exploration; it is likely that permanent damage to the
nerve has occurred at the time of fracture, or a failure of the nerve graft or repair.
We encourage centres to report on their outcomes of traumatic nerve palsies after
paediatric SCHFs to clarify these recommendations and further guide clinicians.

Supplementary Materials: The following supporting information can be downloaded at: https://
www.mdpi.com/article/10.3390/children10121862/s1, Supplementary S1: Search Strategies.
Supplementary S2: PRISMA 2020 Checklist. Supplementary S3: JBI Critical Appraisal Checklist
for Case Control studies. Supplementary S4: JBI Critical Appraisal Checklist for Cohort Studies.
Supplementary S5: JBI Critical Appraisal Checklist for Case Series. Supplementary S6: JBI Critical
Appraisal Checklist for Case Reports. Supplementary S7: Tables S1–S5. References [67–74] are cited
in the supplementary materials.
Author Contributions: C.G.: writing of protocol, data collection, data extraction, results interpreta-
tion, writing of paper, supervision of authors. M.R.L.C.T.: writing of protocol, data collection, data
extraction, results interpretation, writing of paper. G.D.D.: writing of protocol, data collection, data
extraction, results interpretation, writing of paper. J.S.: data extraction, assessment of papers. M.K.:
data extraction, assessment of papers. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable due to the nature of the study.
Informed Consent Statement: Not applicable due to the nature of the study.
Data Availability Statement: Raw data is available on request to the primary author.
Conflicts of Interest: The authors declare no conflict of interest.
Children 2023, 10, 1862 9 of 11

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